Chicago Department of Children and Youth Services Children Services Division Head Start / Child Care Programs Procedures for Referral to Chicago Public Schools Office of Diverse Learner Supports and Services (ODLSS) for Evaluation Child’s Name: Date of Birth: Child’s Primary Language: Primary Home Language: Delegate Agency: Site Name: Name/Title: Contact Phone Number: Classroom Teacher:

Check each task as it is completed: Screening of Child (score indicates that child may be eligible for special education services): o Child ESI-R Screening Decision: Refer Re-screen OK o Date of Initial Screening: Score: o Re-screening of Child: Child’s score on initial ESI-R screening indicated that the child should be re-screened before he or she is referred for evaluation by CPS. Not all children need to be re- screened.  Child ESI-R Score on re-screening:  Date of re-screening: Referral of Child to Disabilities Coordinator or Site Director: Classroom teacher informs Disabilities Coordinator that the child’s score on the screening assessment indicates further evaluation is necessary. This must occur within 5 days of screening. Review of Child Progress: Before meeting with parents, the program site members are encouraged to informally review the child’s performance in program activities. This meeting will help to prepare the CC/HS professionals for the SRT Meeting with the parents. o The team is concerned about this child’s progress and development in the following areas: o Parent concerns that have been shared with staff: o Health history (include information from hearing & vision

screening: Compile Disability Folder Schedule Screening Review Team (SRT) Meeting: Disabilities Coordinator or Designee convenes meeting of team to review the child’s scores and explain the referral process to the parent. The parent, referring teacher, and disabilities coordinator or designee must be present at this meeting. Others may be invited to participate as necessary. This must occur within 15 days of the screening. o Date of Meeting: Identify Child’s Home School: Prior to the SRT Meeting, the disabilities coordinator will call CPS to identify child’s home school and the name of the case manager at the school. o School Name: Address: o Case Manager Name: Phone #: Screening Review Team (SRT) Meeting: o Review the screening results with the parents. Explain that these are only screening instruments 1 that indicate the need for further evaluation. They do not indicate the presence or absence of a disability. Further assessment will be required to determine the child’s eligibility for an IEP. o Explain rights to parents. It is the parent’s decision whether or not to have the child evaluated. o If the parent chooses to have the child evaluated by CPS, he/she is the primary person responsible for bringing the child to CPS for evaluation. Parents may request staff to assist in the process. o If the parent chooses not to have the child evaluated by CPS at the time of the SRT meeting, they may request an evaluation at a later date. o Does the parent choose to have the child referred to Yes No CPS for evaluation? o Joint Screening Referral Consent Form (JSRCF) signed: Yes No o If parent declines, Date: Parent Signature: Referral Packet If the parent agrees to have his/her child evaluated, the Disabilities Coordinator will submit required documentation as outlined in the DFSS Checklist of Contents for CPS referral packet. This will occur within 3 days of the SRT meeting. Review of Referral Packet o DFSS Disabilities Team will review the folder contents within 72 hours of receipt. o DFSS Disabilities Team will forward all documents that support the referral to ODLSS Scheduling Team. o Upon receipt of the folder contents, the ODLSS Scheduling Team will register the child and create a referral.

Date of Registration as a non-attending student at CPS: Monitor Status of CPS Evaluation Disabilities Coordinator or other HS/CC personnel will check with parent to see if CPS has scheduled a date for evaluation. If the evaluation has not been scheduled, the Disabilities Coordinator will follow-up with the Disabilities Team Liaison. o Date of Status Check: Eligibility Meeting In most cases, Eligibility meetings will be held on the same date as the evaluation. Parents may invite HS/CC staff to attend this meeting. o Date of Meeting: Child is eligible for Special Education services (IEP): Yes No o Obtain a copy of the IEP. Monitor IEP Services o Assigned School: o Date of Enrollment:

Transportation Services: COPA Transportation Report is completed and placed in the Disability folder.

Monitor Services. Disabilities Coordinator will monitor services provided by CPS on a regular basis. Monitoring will include: o Assuring that services are being delivered as indicated in the IEP. o Supporting HS/CC Staff in understanding the IEP and assisting the teaching staff in making modifications and accommodations in the classroom to support the IEP goals. o Ensuring current IEP documents are available to the teachers and are placed in the Disability folders. Transition Services: o Monitor transition with CPS Case Manager at Home School to assure transition of disability services to kindergarten.

Form updated 4/3/2018

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